2023 Participant Information Sheet
Cancer Support Community Delaware gathers information annually about every participant, both new and returning, to help us better support you; All information provided is always kept confidential and protected. Thank you in advance for taking time to fill out this form annually.
Name
*
First Name
Last Name
Nickname
if applicable
Contact Information
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City, State
County
Zip Code
Date of Birth
xx/xx/xxxx
Relationship Status
Single
Married
Partnership
Divorced
Widowed
Other
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Emergency Contact Information
Emergency Contact's Name
First Name
Last Name
Emergency Contact's Relationship to you
Emergency Contact's Phone Number
Please enter a valid phone number.
Is this your first time at CSCDE?
Yes
No
If Yes, how did you hear about us? (If you were referred to us by a person please provide their name if applicable)
Which CSCDE location will you/do you participate at? (check all that apply)
New Castle County
Middletown
Kent County
Sussex County
Virtually
Please select the one phrase that best describes why you are participating in our programming this year:
Cancer patient/survivor
Caregiver/support person
Bereaved
Healthcare professional
Other
COVID-19 Vaccination Status
We recommend that you be fully vaccinated and boosted before entering our offices.
I am fully vaccinated against COVID-19 and have received my booster.
Yes
No
CSS (Cancer Support Source)
CSS is a distress screening tool for those who have been diagnosed with cancer, and for caregivers. This short questionnaire allows us to better recommend support programs and services for you. Please note you must also provide your date of birth above, which will be used as your login for the emailed survey.
I would like to participate in the CSS
Yes
No
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Demographic Data
As a non-profit organization that does not charge for our services, we rely on donations to underwrite our programs. The information given in this next section helps us secure funding and will be provided to funders only in terms of combined demographic data of all participants with no identifying information. You answers will not affect your ability to access all programs at CSCDE at no charge.
What is your race/ethnicity? (please select all that apply)
Caucasian
African American
Hispanic
Asian
Pacific Islander
Native American
Other
What is your gender?
Male
Female
Transgender
Non Binary
Other
What is your age?
18-24
25-39
40-55
56-69
70+
What is your current employment status?
Employed (full or part-time)
Medical Leave
Disabled
Retired
Unemployed
What is your annual household income?
Under $25,000
$25,000 - $49,000
$50,000 - $74,000
$75,000 - $99,000
Over $100,000
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Cancer patients/survivors only
Please complete the following:
Year of cancer diagnosis:
Type of current, primary cancer:
Bladder/Urinary
Brain
Breast
Colon/ Rectal
Head/ Neck
Prostate
Liver
Lymphoma
Melanoma/skin
Multiple Myeloma
Ovarian/Uterine/Cervical
Pancreas
Leukemia (acute or chronic)
Lung
Myeloproliferative Neoplasm (MPN)
Essential Thrombocythemia (ET)
Myelofibrosis (MF)
Polycythemia Vera (PV)
Kidney
Stomach
Other
If other, please specify:
Insurance Type:
Medicare only
Medicare and private
VA Hospital
Medicaid
Private
Uninsured
Canadian
Other
Cancer center/hospital where being treated:
Oncologist's name:
Thank you for taking the time to answer these questions!
Submit
Should be Empty: